John L. Marshall -- How health-care reform can cure cancer

How did we end up here? The answer is simple: Cancer patients are scared for their lives and will accept what is offered, and we oncologists want to offer improved outcomes and recommend the best treatments we can. Insurance will pay for these treatments. A portion of fees collected by cancer doctors and hospitals is based on how much chemotherapy we administer. So the more drugs we give, the more radiation we give, the more we collect from health insurance. The incentive system makes it less lucrative to talk to patients -- to counsel them, to help with their decision-making -- than to treat them, regardless of the value of the treatment.

A major focus of health-care reform is for doctors to practice evidence-based medicine: to offer therapies that have been proven to help patients live longer or, at least, live better. The problem in cancer medicine is that we have very little evidence to support what we are doing. Because so few of our patients enter clinical trials, we have no way of tracking their outcomes collectively, and we learn almost nothing from them. Our understanding of cancer therapies comes from the 5 percent of patients who enroll in trials, a tiny database when we consider the highly variable nature of the disease. In fact, most of our evidence has not come from clinical trials performed in the United States but from nations where patients have little access to advanced care except through participation in such trials.

In this country, the highest hurdle we must leap is our patients' expectations. Cancer patients facing death want treatment; they want hope that they will be cured, even if they have been told that they cannot be cured. They will try toxic treatments over and over, hoping to extend their lives. We physicians are co-conspirators. Of course, we also want to believe that the next treatment will help more than the last, even though we know that is rarely the case. What if we had to pay for all this out of our pockets? Would we pay that much for some possible hope?

I believe we can invest more in actual hope. To do so, we must further explore the genetic makeup of patients and their cancers. We can no longer diagnose cancers using only a microscope. We must profile them at a molecular level to determine precise treatments, instead of using our current trial-and-error approach.

To assess a patient's specific genetic problem, we must understand all the possible permutations and patterns. This will come only from a comprehensive clinical database -- a high priority of the administration's reform plans. For example, we know there are at least four different types of breast cancer; they look exactly the same under a microscope but are very different diseases. The repeated biopsies and blood tests that are needed, none of which is covered by most health insurance plans, will become critical to finding our answers.

The future of cancer care will rely on personalized medicine. This requires a significant change to our medical system, which is built around one size-fits-all treatment and seemingly unrestricted access to care. The system answers our emotional needs and provides some hope for a cure, but moves us forward only a few yards at a time.

Oncologists are optimists, and I am proud to be among them. I truly believe we can cure cancer. I care greatly for my patients and am doing everything in my power to improve and lengthen their lives. When I offer a clinical trial to a patient, I am hopeful that it will be better than the standard treatment. I am optimistic that health-care reform will not simply provide everyone with insurance that will cover the "standard of care" but will also force us to determine the true value of treatments.

There is nothing that focuses the mind more than a cancer diagnosis. I can assure you that all of my patients have very clear vision and have shifted their priorities. We as a country must do the same on their behalf. Health-care reform -- and a better understanding of what we're paying for when we treat these terrible diseases -- will help focus our approach to caring for cancer patients and finding a cure.

John L. Marshall is the director of the Otto J. Ruesch Center for the Cure of Gastrointestinal Cancers at the Lombardi Comprehensive Cancer Center at Georgetown University. He will be online to chat with readers on Monday at noon. Submit your questions and comments before or during the discussion.